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Coach Donna’s 2015 “Spring Camp”
1) Skater’s Name ______________________________________________________________________
Date of Birth _________/__________/________________
Team most recently played _______________________________________________________________________
2) Skater’s Name _______________________________________________________________________
Date of Birth _________/__________/________________
Team most recently played
_______________________________________________________________________
Parent’s Name Mother__________________________________________________________________
Father___________________________________________________________________
Emergency Contact Number – cell phone if possible! Mother__________________________________________________________________ Father___________________________________________________________________
Full Week $375 _______
Individual days $90 _______
Late Pick-up after 3:30pm - per day $20 _________
Make payable and mail check to:
Donna Helgenberg P.O. Box 516 Media PA 19063
Circle days participating:
Monday Tuesday Wednesday Thursday Friday
Hold Harmless Agreement:
Having full knowledge of the dangers and risks associated with sports, I hereby certify that my child is fully covered under my personal medical insurance for any bodily injury that may occur and assume full responsibility for all losses and injuries sustained while involved in this camp. I also hold harmless the Skatium, Donna Helgenberg, any camp associates and rink employees from any claim related thereto.
Parent signature _____________________________________________________________ Date_______________________________________________________________________
1) Skater’s Name ______________________________________________________________________
Date of Birth _________/__________/________________
Team most recently played _______________________________________________________________________
2) Skater’s Name _______________________________________________________________________
Date of Birth _________/__________/________________
Team most recently played
_______________________________________________________________________
Parent’s Name Mother__________________________________________________________________
Father___________________________________________________________________
Emergency Contact Number – cell phone if possible! Mother__________________________________________________________________ Father___________________________________________________________________
Full Week $375 _______
Individual days $90 _______
Late Pick-up after 3:30pm - per day $20 _________
Make payable and mail check to:
Donna Helgenberg P.O. Box 516 Media PA 19063
Circle days participating:
Monday Tuesday Wednesday Thursday Friday
Hold Harmless Agreement:
Having full knowledge of the dangers and risks associated with sports, I hereby certify that my child is fully covered under my personal medical insurance for any bodily injury that may occur and assume full responsibility for all losses and injuries sustained while involved in this camp. I also hold harmless the Skatium, Donna Helgenberg, any camp associates and rink employees from any claim related thereto.
Parent signature _____________________________________________________________ Date_______________________________________________________________________
